By Danielle Martin, M.D., Ashley P. Miller, M.D., Amélie Quesnel-Vallée, Ph.D., Nadine R. Caron, M.D., Bilkis Vissandjée, Ph.D., Gregory P. Marchildon, Ph.D.
The Lancet, February 22, 2018
* Canada’s universal, publicly funded health-care system—known as Medicare—is a source of national pride, and a model of universal health coverage. It provides relatively equitable access to physician and hospital services through 13 provincial and territorial tax-funded public insurance plans.
* Like most countries that are members of the Organisation for Economic Co-operation and Development (OECD), Canada faces an ageing population and fiscal constraints in its publicly funded programmes. Services must be provided across vast geography and in the context of high rates of migration and ethnocultural diversity in Canadian cities.
* In 2017, the 150th anniversary of Canadian Confederation, the three key health policy challenges are long waits for some elective health-care services, inequitable access to services outside the core public basket, and sustained poor health outcomes for Indigenous populations.
* To address these challenges, a renewal of the tripartite social contract underpinning Medicare is needed. Governments, health-care providers (especially physicians), and the public must recommit to equity, solidarity, and co-stewardship of the system.
* To fully achieve the potential of Medicare, action on the social determinants of health and reconciliation with Indigenous peoples must occur in parallel with health system reform.
* Without bold political vision and courage to strengthen and expand the country’s health system, the Canadian version of universal health coverage is at risk of becoming outdated.
Canadian lessons for a global world
Canada’s most important accomplishment by far has been the establishment of universal health coverage, which is free at the point of care, for medical and hospital services. The preservation and enhancement of Medicare are due largely to Canadians’ pride in caring for one another—an expression of equity and solidarity that runs core to Canadian values. Hinging on a social consensus of equitable access to health care, the simplicity of the system—no variable coverage, no means testing, and no co-payments—is easy for Canadians to understand and support.
But universal health coverage is an aspiration, not a destination. All countries must continuously consider the depth and scope of coverage that is politically achievable and fiscally feasible. In Canada, that necessary work has not been done for more than 40 years. The Canadian experience thus offers a cautionary tale on incrementalism. In the absence of bold political vision and courage, coverage expansion can be very difficult to achieve, with the result that the Canadian version of universal health coverage is at risk of becoming outdated.
A powerful mechanism such as a single-payer insurance system is only as good as the willingness of system leaders to use it for reform. In turn, reform requires a willingness on the part of governments to pursue change, rather than simply managing the status quo. Clear mechanisms are lacking to consistently realign resources to meet population needs, promote evidence-based care, reduce variation, and contain costs. Health care is ultimately a local affair, and no patient or provider wants the payer in the examination room. However, much of the potential benefit of a single-payer structure is lost when institutions are independent, with little accountability. The potential of the system is further limited by the fact that physicians function alongside but outside the system, rather than as accountable participants through employment or other contractual means. Co-stewardship and accountability should be recognised as integral parts of payment systems rather than avoided or grafted on afterwards.
When Tommy Douglas first established public health insurance in Saskatchewan in the late 1940s, his goal was to begin by creating insurance models that would eliminate the financial barriers to care. He intended to follow that with a second reform of health service delivery that would focus on population health needs, with an emphasis on the reform of delivery models and on the social determinants of health. His government, and subsequent governments, provincially and federally, managed to overcome fragmented institutional structures and decentralisation of power to make the first stage of his vision a reality, but not yet the second. To achieve that second stage in the 21st century, determined action on the social determinants of health and a joint effort by governments, health-care providers, and the public in achieving health system reform will be needed. With bold political vision and courage, this ambitious goal is within reach.
Canada’s global health role: supporting equity and global citizenship as a middle power
By Stephanie A. Nixon, Ph.D., Prof Kelley Lee, D.Phil., Prof Zulfiqar A. Bhutta, Ph.D., Prof James Blanchard, Ph.D., Prof Slim Haddad, Ph.D., Prof. Steven J. Hoffman, Ph.D., Prof. Peter Tugwell, M.D.
The Lancet, February 22, 2018
* Canada boasts long-standing and active engagement in global health, shaped by the country’s history of nation building and middle-power status. Ongoing nation building emphasises consensus building and equity in foreign policy, and relies on strong commitment to multilateralism.
* Canada’s unique strengths in global health leadership draw from the country’s legacy and contemporary challenges of building a multicultural society, maintaining a bilingual heritage, and reconciling the injustices inflicted on Indigenous peoples. Health equity has been a key focus.
* The quality of Canadian contributions to global health has been high, but impact has been diluted by a tendency to spread limited resources thinly, and by fragmentation among global health institutions, priorities, and policies in Canada.
* The previous Conservative federal government, led by Stephen Harper, adopted an approach to foreign policy that favoured technocratic solutions and tied global health initiatives to trade and investment opportunities benefiting Canada. It championed maternal and child health in the Millennium Development Goal era, but critics say this period was a sharp departure from traditional Canadian values of equity, human rights, and global citizenship.
* High expectations exist for the current Liberal government led by Justin Trudeau, which has signalled a return to these traditional Canadian values. Canada now has an important opportunity to assert much-needed global leadership, including in global health. Real policy change and concrete action on issues such as foreign aid assistance and Indigenous health inequities are urgently needed to demonstrate the credibility of the government’s commitment to these values.
Canada was formed 150 years ago, bringing together a vast land at risk of being subsumed by its larger neighbour to the south. The political forging of the country came at a considerable price, notably to Indigenous peoples, and the country has learned hard lessons about the importance of inclusion and equity. Moreover, Canada’s unique history continues to unfold. Authentically reconciling its relationship with Indigenous peoples, maintaining social cohesion amid diversity, and successfully meeting domestic needs while remaining open to globalisation will be integral to the country’s next 150 years. Against this backdrop, Canada is uniquely positioned to become a more prominent global health leader by harnessing its distinct experiences, diverse assets, and core values. Like the country itself, Canada’s role in global health remains a work in progress.
By Don McCanne, M.D.
This two part series on Canada’s health system, published in The Lancet, provides an excellent overview and update on their system. It is closest to the model that single payer advocates in the United States support. But we have much to learn from Canada – both on what does work and what doesn’t. These articles should be downloaded and retained as invaluable reference sources for our work here in the United States.
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